A Rare Case of Simultaneous Recurrent Bilateral Hypertensive Thalamic Hemorrhage: A Rare Case Report

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A Rare Case of Simultaneous Recurrent Bilateral Hypertensive Thalamic Hemorrhage: A Rare Case Report

Abdolreza Ghoreishi¹ , Ghazal Malekmahmoudi^1* , Mohammad Hadi Molseghi² , Mehrdad Gholizadeh¹ , Mansoureh Sabzehparvar¹ 1. Department of Neurology, Vali-e Asr Hospital, School of Medicine, Zanjan University of Medical Science, Zanjan, Iran.

2. Department of General Surgery, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran.

* Corresponding Author:

Ghazal Malekmahmoudi, MD.

Address: Department of Neurology, Vali-e Asr Hospital, Zanjan University of Medical Sciences, Zanjan, Iran.

E-mail: [email protected]

Intracerebral hemorrhage is a dangerous occurrence in patients. This may occur due to hypertension, cerebral amyloid angiopathy, Drug usage, anticoagulants, antithrombotic, coagulopathies, tumors, arteriovenous malformation (AVM), and aneurysmal rupture.

Bilateral thalamic hemorrhages are rare. This article presents a rare case of Simultaneous recurrent bilateral hypertensive thalamic hemorrhage in a 57-year-old woman with right hemiparesis.

A B S T R A C T

Running Title Recurrent Bilateral Hypertensive Thalamic Hemorrhage

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Keywords:

Hypertension; Bilateral thalamic hemorrhage; Thalamus;

Hemiparesis

Case Report

Introduction

ntracerebral hemorrhage is a dangerous and potentially life-threatening compli- cation, and the most common etiologies are hypertension, anticoagulation, aneurysmal rupture, catastrophic antiphos- pholipid antibody (APLA) syndrome, and comorbidities [1-6]. Bilateral thalamic

hemorrhages are rare. We report a case of hypertension with unilateral thalamic hemorrhage due to hypertension which progresses to bilateral hemorrhage. No other cause for bleed was found, despite an exhaustive search.

Case Report

A 57-year-old Iranian woman with known hypertension and previous cerebrovascular accident (CVA) was

I

Article info:

Received: 02 August 2021

Revised: 15 August 2021

Accepted: 04 September 2021 Special Issue 2021, Volume 6

284

Citation Ghoreishi A, Malekmahmoudi G, Molseghi MH, Gholizadeh M, Sabzehparvar M. A Rare Case of Simultaneous Recurrent Bilateral Hypertensive Thalamic Hemorrhage: A Rare Case Report. Case Reports in Clinical Practice. 2021; 6(Special Issue):284-287.

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admitted to the hospital with a chief complaint of right hemiparesis with paresthesia and facial paresis. At first, her symptoms were mild and then gradually intensified.

She had no history of medical diseases. She also had no history of medication and had no history of trauma.

There was no history of hematemesis, hemoptysis, epi- staxis, or menorrhagia. She had a history of the same symptoms 2 years ago, which diagnosed bilateral thalamic infarction proved by Magnetic resonance imaging (MRI) (the causes were unclear). The patient had nausea and vomiting before admission. On examination, she was conscious but drowsy and was obeying commands.

She was non-febrile with a pulse rate of 88 beats/min, blood pressure of 160.90 mm/Hg, and respiratory rate of 16 min. She had pallor but no edema or icterus.

Cardiovascular and respiratory system examination revealed no abnormality, and the muscular force of the right side was determined to be 2.5. Her laboratory findings are shown in Table 1. Her chest X-ray and electrocardiogram were normal. First, a non-contrast computerized tomographic scan of the head was car- ried out to evaluate her symptoms, which revealed unilateral left thalamic hemorrhage (Figure 1-A). The patient was monitored with the diagnosis of unilateral thalamic hemorrhage due to hypertension. She was ini- tially treated with anti-hypertensive drugs. On the third day of admission, the patient became drowsy. CT scan

was repeated for the patient, which showed bilateral thalamic hemorrhage (Figure 1-B).

Cerebral deep vein thrombosis is one of the causes of bilateral thalamic hemorrhage. The patient was exam- ined for MRI, Magnetic Resonance Venography (MRV), and D-Dimer. Brain MRI and MRV of the brain were normal. The serum level of D-Dimer was 0.53 microgram/

ml (normal range of 0.3-2). At last, the patient was treated with the diagnosis of bilateral thalamic hemorrhage in hypertension. In the course of hospitalization, her clinical condition improved with proper control of her blood pressure. After 10 days, the patient was dis- charged from the hospital in good health status.

In the 1^st month after discharge, her clinical condition was good, and there were no new findings in her history and physical examination.

Discussion

The presented case is an unusual Stroke manifestation due to a bilateral thalamus hemorrhage. Only 11 bilateral simultaneous thalamic hemorrhage cases have been reported based on the searches, including our patient (Table 2) [1-11]. In this series, 6 issues were be- cause of hypertension. Other causes of bleeding include asphyxia, deep vein thrombosis, coagulation factor dis- order, and other reasons. Unilateral or bilateral thalamic

Figure 1. Computed tomography and MRI of patient

(A) Computed tomography and MRI T2 show unilateral thalamic hemorrhage. (B) Computed tomography and MRI T1 show bilateral thalamic hemorrhage

A

B

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Ghoreishi A. et al. Recurrent Bilateral Hypertensive Thalamic Hemorrhage CRCP. 2021; 6(Special Issue):284-287 285

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hemorrhages are often thought to be due to hypertension; therefore, no vascular lesions, such as aneurysms or AVMs, are observed [4, 8].

Clinical experience has shown that in bilateral thalamic hemorrhages, the cause of hemorrhage is usually the incidence of deep vein thrombosis, which should be rapidly treated with high-dose heparin, which the

Table 1. Laboratory Results

Lab test Result Lab test Result

White Blood Cell Count 11.4 x103/µL Na 137mEq/L

Hemoglobulin 13.5 Gr/dL K 3.9mEq/L

Platelets 238000 x103/µL Ca 8.7 mg/dL

Fasting blood glucose 79 mg/dl Mg 2.6 mg/dL

PT 13 Sec INR 1

PTT 26 Sec

FANA <1:10 D-Dimer 0.53 µgr /ml

Anti MPO IgG 3 U/ml

Anti PR-3 Ab 2.1 U/ml

Anti ds-DNA IgG 1.7 U/ml

Anti-cardiolipin Ab IgG 1 GPL/ml

Anti-cardiolipin Ab IgM 0.3 MPL/ml

Lupus Anticoagulant 42 Sec

Table 2. Cases of multiple intrathalamic and bilateral thalamic hemorrhage

Case Report Reference Clinical Presentation Radiology

58-year-old male Kono et al., 2014 [3] Sudden right mild hemiparesis

Bilateral thalamic hemorrhage on CT. 17 microbleeds in putamen and thalamus seen on Gradient echo magnetic reso-

nance sequences images 35-year-old male Yi et al., 2013 [4] Sudden loss of consciousness Multiple ICH including those in the cer-

ebellum, basal ganglia, and thalamus 54-year-old male Imai et al., 2000 [5] Semicoma, quadriplegia and skew

deviation CT showed B/L thalamic hemorrhage 76-year-old female Kohshi et al., 2000 [6] Right hemiparesis CT with right thalamic hematoma and

left putaminal bleed 60-year-old male Sunada et al., 1999 [7] Sudden unconsciousness and left

hemiparesis CT with B/L thalamic hemorrhage 65-year-old male Kabuto et al.,1995 [8] Sudden coma CT with B/L putaminal and thalamic

hemorrhage

80-year-old female Kabuto et al., 1995 [8] Sudden unconsciousness CT with B/L thalamic hemorrhage 64-year-old male Lin et al., 1993 [9] Quadriparesis CT with B/L thalamic and putaminal

hemorrhage 71-year-old female Hickey et al., 1983 [10] Decerebrate posturing and ataxic

respiration

CT scan showing a large hematoma in the right basal ganglia and thalamus and

also an area of hemorrhage in the left internal capsule and thalamus.

286 Ghandi Y. et al. Kawasaki Disease: Bloody Diarrhea with Acute Myocarditis CRCP. 2021; 6(Special Issue):^284-287

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prognoses will be good. All the patient’s neurological symptoms will resolve [7, 9]. In the patient, according to normal results of the evaluation for other causes of thalamus hemorrhage and considering the long history of hypertension in the patient, hypertension can be de- scribed as the cause of bilateral thalamus hemorrhage, and we can roll out other causes. The patient was not in critical condition due to the manifestation of hospitalization; then, no emergent action was needed.

The clinical presentations of this disease are not nec- essarily specific. Patients may have presented vari- ous neurological signs such as dysarthria, tetraparesis, and pseudobulbar paresis [2, 4]. Our patient exhibited hemiparesis and paresthesia, which suggests unilateral damage. The unique point of our patient is that it was a recurrent bilateral thalamic insult (first, it was bilateral thalamic ischemia, and then, after two years, sequential bilateral thalamic hemorrhage happened). She was first admitted with left thalamus hemorrhage, and then she progressed to bilateral thalamic hemorrhage. The cause of this progression under the control of patients’ blood pressure is unclear.

The authors certify that they have obtained all appro- priate patient consent forms. The patient has given her consent form for her images and other clinical information to be reported in the journal. The patient under- stands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Ethical Considerations

Compliance with ethical guidelines

All ethical principles are considered in this article. The participants were informed of the purpose of the research and its implementation stages. They were also as- sured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

A written consent has been obtained from the subjects.

principles of the Helsinki Convention were also observed.

Funding

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Conflict of interest

The authors declared no conflict of interest.

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